Beth, a single, twenty-five-year-old woman, called me for an appointment with complaints about anxiety, melancholy, insomnia, and confusion as to what to do with her life. What struck me from our initial phone conversation was that there was confusion even in her complaints. What exactly her problem was, was not clear.
When I first met Beth for evaluation in my office, I immediately appreciated her high energy and intense presence. I also felt a prickly standoffish quality to her. She told me again about the various symptoms that bothered her. When I asked about her treatment history, I learned I was her tenth therapist. She had called me, a psychiatrist, assuming she needed medication because of a lack of relief from prior therapies. Asking about her prior therapists and her relationship with them revealed Beth’s critical view of those trying to help her. One therapist was too chummy. One was too defensive. One therapist’s memory wasn’t good enough. There was something wrong with everyone. In then asking about her social and romantic history, I learned that she had never had a romantic relationship.
What was going on here, I wondered to myself? As I observed her standoffishness and heard about her difficulty engaging with others, I also felt a sweet, gentle quality in Beth below the surface. As I asked more questions to better understand her and her difficulties I was hit with a left hook.
“You don’t know the difference between fewer and less?!” Beth exclaimed with a look of contempt.
It was so jolting I couldn’t even recall what I had just asked. I didn’t speak properly enough. There it was! We were connecting about her problems, and I was on the right track focusing not on her symptoms but on her overall way of handling her feelings, her character, and she nailed me about my grammar. I paused, stunned, and then gathered myself.
“Wow. What’s that about?” I asked. “I felt like I was right in your cross hairs!”
She didn’t respond directly to my question, but I knew that she was aware of what had just happened as she laughed it off and moved onto another subject. I learned in that first session that besides attacking others through her criticism, she had various other ways of disconnecting from her feelings. She might “laugh it off,” “shrug them away,” or simply change the subject with an abrupt “anyway!”
Despite her push back and prickly quality, I felt I made a good connection with Beth during that initial consultation. I could tell that she was genuinely suffering, was longing for a trusting connection, and was earnest in her efforts. I had the distinct impression that working with her was going to be well worth the effort for both of us. At her second appointment, Beth literally told me, “You passed the test.” She made it clear that she trusted me enough to develop a deeper doctor-patient relationship and although she was still very muted in her emotional expression, she told me something very important, “I feel I could cry with you. I don’t have that with anyone.” She was relieved that she found someone she could trust enough to start addressing her emotional problems. I was relieved that she was able to give up her tough prickly façade so quickly and begin work.
These two initial sessions were the beginning of Beth’s first year in therapy which developed a routine and set the foundation for our relationship and mutual trust. I quickly learned that asking, “How are you feeling?” or “How are you doing?” was much too broad and too emotionally charged for her. Proceeding in this way caused Beth to become confused and immobilized. What did work was addressing specific questions and ideas that she planned in advance of her sessions, though not necessarily all of them. Just writing topics down, whether ideas or feelings, was a big step for her. Anytime something emotionally charged came up she quickly got away from it with her “anyway,” “moving on,” or other segues that caused us to laugh as we connected over the fact that we both knew that she wasn’t yet ready to deal with such intensity, and that this was okay with me. Early in our work together, I saw fleeting expressions of worry or sadness on her face, especially in her eyes and forehead, but I knew that calling attention to them in any way until she was ready would be counterproductive. I carefully and consistently pointed out how she diminished her feelings or guarded them from me session after session. I learned that although she had some initial, superficial trust it was going to take time to work through her deeper mistrust and develop a stronger bond in which she could be comfortable enough to reveal herself more.
Even with her mistrust, she also had a deep yearning to be seen, heard, and accepted. By paying attention to her needs and by truly “hearing” her, I could help strengthen our bond. In this regard, Beth also brought up what she referred to as “ice breakers.” These were intriguing questions that were on her mind which allowed her to get to know me better while also being in charge. Letting her know something about me or how I saw the world helped her gain another perspective and to feel that she could trust me more. I just had to be aware of appropriate boundaries and knowing what was helpful for our therapeutic relationship and what would be too much and counterproductive. In her sessions, I was learning from Beth by listening to her and observing her where she was emotionally, what she could tolerate, and what she needed and didn’t need. Essentially, she determined the content of individual sessions while I monitored her capacity for emotional perception and expression and her therapy overall.
One way in which Beth did open up about her thoughts and feelings during her first year in therapy was by writing essays for me to read. They were about her childhood, current problems, and everything in between. They conveyed her intensely felt emotions, sensitivity to her internal feelings and the world around her. It was moving to know that her trust was deepening and to hear more about what she briefly touched on during her sessions. Additionally, it allowed me to show her that I was going to put in the effort to hear her out. She took a chance in trusting that I would take the time, care about what she had to say, and allow her to express herself without judgement. Early on in her therapy, I was aware of her high energy level, her shallow breathing, and her tendency to think in place of feeling, all of which served to dampen down her emotional excitement. So, I recommended jogging. The goal was to help her connect with her physical body and her emotions, discharge some of her energy, and “clear her mind” when stuck with ideas that prevented her from moving forward.
It wasn’t until Beth’s second year of therapy that I began to sense that within a more trusting therapeutic relationship and with a stronger emotional foundation she could tolerate increased emotional intensity and spontaneity. Hence, I delicately encouraged her to let go of some of the structure that she had developed to control her therapy sessions. She continued to take charge with her icebreakers, preplanned talking points, and segues as a matter of course but I was now able to ask Beth, “How are you feeling?” though I always made sure to keep an eye on how she was doing, if she was on the verge of being overwhelmed, or if she could take a chance. She not only allowed herself to simply feel whatever was there, but she became more expressive with my encouragement as therapy progressed. She used her “anyway” and “moving on” segues more sparingly. We were able to talk spontaneously at times about what was on her mind or what mattered in that moment rather than referencing preplanned “talking points.” It was wonderful to be a part of her transformation and I let her know it. She could be hard on herself and often didn’t see what I could see—an earnest young woman fighting for her life to deal with longstanding problems, trying to better connect with herself and others, and to feel more satisfied with life.
Also in her second year of therapy Beth mentioned that she was training for a half marathon! Up until that point I knew that she was jogging as I had recommended but I hadn’t known quite the extent to which she had taken up the challenge and with such gusto. I saw it as more than just a sign of her capacity for physical exertion. This showed an increasing ability to use her strong drive and tenacity to meet her problems head on. Along with this came more discussions about more intense aspects of her life including her childhood and family, intense, longstanding feelings about being incompetent, not belonging, and feeling alone, and the prospects of having a love life. Beth’s ever-present mistrust came up time and again and peaked momentarily when she had a question about which path to take in her work life. I was curious about how little we talked about her dilemma in how to proceed with a new role in her company and when I mentioned it, she snapped, “Your job is to support your patients!” I encouraged her to tell me more and it became clear that my frequent observations and comments about how hard she was working and how well she was doing were intolerable and led to her doubting my sincerity and feeling mistrustful. She revealed her self-criticism and frequent absence of satisfaction and contentment.
After doing so, Beth relaxed and appeared relieved, and genuinely asked for my perspective.
Beth began to more regularly work laying down on the therapy couch. This helped to address the emotions held in the tense muscles in her forehead and occiput and allowed her to breathe more fully. Simply laying down and breathing with encouragement to exhale through her mouth and allow sounds to come out often brought emotions to the surface. Gentle massage of her forehead and the supraorbital arches over her eyes allowed her face to relax and for her to more fully express her worry, emptiness, and sadness that were only partially apparent early on. I learned that Beth was right. She could cry with me. She let a few tears fall in one session and then a few weeks later let out some soft crying.
During Beth’s third year of therapy, she was ready to date. Up to this point, we hadn’t discussed men or romance though I wondered how she was looking at her love life. I waited for her and didn’t press. As I saw it, she had developed a foundation of trust and openness in her therapy, allowed herself to relax some of her rigid ways of interacting with me, and now was ready to take her new capacity for functioning out into the world. She was ready but she still needed support. “Dr. Burritt, if you hear any ‘red flags’ with the guys I go out with, will you tell me or will you let me figure it out on my own?” It wasn’t apparent in her expression or voice, but I heard her mistrust and a deep fear in her question. I unequivocally told her that I wouldn’t leave her hanging. She let out a sigh of relief.
Although Beth was a great conversationalist, was funny and interesting, she was new to dating or meeting with someone for the sole purpose of romantic pleasure. She was working through not only her feelings but also years of training from her family, friends, and culture about how she was supposed to talk to the opposite sex, date, and have a romantic relationship. In fact, as she described how she was on some of her dates, she sounded formal, structured, and when most anxious, like an interviewer or interrogator. I had to help her see what was going on.
“Why are you going out with Steve?” I asked during one session. “To see if he could be someone I want to date. Maybe be a boyfriend,” Beth answered matter-of-factly.
“I would look at it differently,” I said. “You’re going out with him to have fun. If you have fun, you can get together again. It might be one date. It might be ten. Instead of ‘going on a mission,’ just take it one step at a time. Your only mission right now, is to enjoy yourself! If a relationship develops then you can take it one step at a time. There’s no rush.”
One month later, Beth came in for her session and excitedly asked me, “Can you believe I’m dating? This is something I’ve been working toward for a long time!”
I proudly responded, “You’re doing a great job!” Beth paused and looked at me seriously and with a complete absence of mistrust.
“You’re doing a great job. Thank you.”
As Beth became more comfortable dating, she faced a new challenge: being clear about how she felt about someone and seeing if and how she disconnected from intense feelings. One way this came up was her “friend zoning” a guy she went out with. Unclear about how to proceed and unsure of her feelings, she jumped to the conclusion that she should “just be friends” with him.
To tackle this, I encouraged her to discuss with me the young man she was going out with, what it felt like to be with him, and what attracted her to him or repelled her. Again, I suggested she take her time and let her conclusion about her romantic interest and attraction to him reveal itself. In effect, she was jumping to a conclusion to avoid her feelings, whether anxiety or pleasure.
Her work in therapy and in her daily life paid off and after many months of dating she met Ryan, a young man whom she felt attracted to and comfortable with. “Dr. Burritt, I was so anxious, but I asked him if he wanted to date exclusively. He said yes! I was surprised, I don’t know why, but it was such a relief! It was just like you said. My anxiety was just me wanting to ask him blocked by my fear. I don’t feel anxious at all right now!” This was a momentous milestone and we both felt proud of her courage.
New challenges came with her relationship: Should they “define the relationship?” Was dating exclusively the same as being “boyfriend and girlfriend”? We discussed these ideas, and while I helped give her perspective I also now at times encouraged her to talk to him. For me, it was a constant feeling out of what she needed to discuss in her therapy and what she could handle bringing up to Ryan. She was pleasantly surprised as he showed himself to be patient and open. No matter the challenge that came up, he was willing to discuss it with Beth. Part of her work then, too, was being clear about what was her contribution and what was his when a conflict arose. Was she being too pushy and controlling? Was she being reasonable? Was he shying away from the conflict or withdrawing? Was there something about him that rubbed her the wrong way? Was it something she needed to accept or was it truly a deal breaker?
As their relationship developed and they became closer, Beth was able to reach another milestone. Now able to feel and express her emotions in the safety of her therapy, she was now more willing to courageously express her stronger feelings to Ryan. Beth even allowed herself to cry with him. Three years earlier she was full of mistrust, rigid, and had a hard time being close with others. She had no one she could cry with. Now, she has both her therapist and her boyfriend. Neither Beth nor I know what comes next, but Beth and Ryan are happily together as boyfriend and girlfriend, and Beth is more satisfied with life than ever.
Discussion: Beth’s case and treatment highlight the therapist’s need to be clear about a patient’s character, her central characteristic way of handling unpleasant or difficult emotions, as well as being in tune with the level at which the patient is functioning. It wasn’t enough to just be aware that Beth was sensitive and mistrustful. It was vitally necessary to be vigilant about how and when to address these aspects of her defenses so that she could open up, first in therapy and then to the world, so that her loving, gentle, and free nature could reveal itself.
Edited and posted with permission of the ACO.